Court’s in Session: The “Swiss Cheese” of Postoperative Deterioration

Deterioration in the intraoperative and immediate postoperative period doesn’t always trigger escalation. Normalisation of clinically abnormal vital signs or assessment findings in this group of patients is common in the immediate post operative period. In most instances this is a protective strategy and ensures we can make rapid decisions. Based on previous experience, our brain forms pathways to allow rapid decision making based on likely or expected trajectories. Our bedside assessment skills get used to determine which patients are recovering as anticipated, and which ones are not progressing. But what happens when we get it wrong, can we have the right flags in place that set a limit on how long we normalise the abnormal, or which patient subgroups we allow variances to be normalised.

This session tracks the path of an otherwise well patient, from the time they arrive in PACU in a hypoxic state, to their premature discharge from PACU and intermittent deterioration overnight with no escalation. Learning focuses on the importance of patient assessment, clinical handover, documentation and how cognitive bias and normalisation of the abnormal can be our enemy in cases of deterioration as we explore a coronial case that focuses on the swiss cheese model of human factors and patient safety.

This course is relevant to you if you are interested in understanding how to avoid cognitive bias, optimise clinical handover and patient assessment to facilitate timely escalation of clinical deterioration.